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2008, Vol. 22, No. 5 (pp. 353-365)
ISSN: 1172-7047
Leading Article
Internet Addiction
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CNS Drugs 2008; 22 (5): 353-365
L
EADING
A
RTICLE
1172-7047/08/0005-0353/$48.00/0
2008 Adis Data Information BV. All rights reserved.
Internet Addiction
Definition, Assessment, Epidemiology
and Clinical Management
Martha Shaw and Donald W. Black
Department of Psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine,
Iowa City, Iowa, USA
Internet addiction is characterized by excessive or poorly controlled preoc-
Abstract cupations, urges or behaviours regarding computer use and internet access that
lead to impairment or distress. The condition has attracted increasing attention in
the popular media and among researchers, and this attention has paralleled the
growth in computer (and Internet) access.
Prevalence estimates vary widely, although a recent random telephone survey
of the general US population reported an estimate of 0.3–0.7%.
The disorder occurs worldwide, but mainly in countries where computer access
and technology are widespread. Clinical samples and a majority of relevant
surveys report a male preponderance. Onset is reported to occur in the late 20s or
early 30s age group, and there is often a lag of a decade or more from initial to
problematic computer usage.
Internet addiction has been associated with dimensionally measured depres-
sion and indicators of social isolation. Psychiatric co-morbidity is common,
particularly mood, anxiety, impulse control and substance use disorders. Aetiolo-
gy is unknown, but probably involves psychological, neurobiological and cultural
factors.
There are no evidence-based treatments for internet addiction. Cognitive
behavioural approaches may be helpful. There is no proven role for psychotropic
medication. Marital and family therapy may help in selected cases, and online
self-help books and tapes are available. Lastly, a self-imposed ban on computer
use and Internet access may be necessary in some cases.
The use of personal computers (PCs) is common- jaoude et al.[2] reported that 69% of the respondents
place in contemporary society. Surveys show that were regular Internet users and, of this number,
over 60% of American households have at least one 5.9% felt their relationships suffered as a result of
PC, and nearly 55% of households are connected to excessive Internet use, 8.7% attempted to conceal
the Internet.[1] Not unexpectedly, as PC use and non-essential Internet use, 3.7% felt preoccupied by
Internet access have become widespread, so have the Internet when offline, 13.7% found it hard to
reports of their misuse, the extent of which was stay away from the Internet for several days at a
recently documented in a telephone survey of 2513 time, 8.2% utilized the Internet as a way to escape
randomly selected adults. In this survey, Abou- problems or relieve negative mood, 12.3% had tried
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354 Shaw & Black
to cut back on Internet use (of whom 93.8% were tion, marital discord and financial problems, are out
of the public’s view.
successful) and 12.4% stayed online longer than
intended either very often or often.
Apart from survey data, excessive or inappropri- 1. Definition and Classification
ate use of computers and the Internet has been the
subject of increasing attention in the professional The appropriate classification of Internet addic-
literature and popular media. The term ‘Internet tion has been debated. Some investigators have
addiction’ has been used to describe this phenome- linked Internet addiction to addictive disorders,
non; its rising profile parallels the introduction and grouping it alongside alcohol and drug use disor-
spread of affordable PCs and the growth of Internet ders.[7] Others have linked Internet addiction to ob-
access now available worldwide. The earliest re- sessive-compulsive disorder (OCD)[10] or to the im-
ports on this phenomenon date back to the 1970s pulse control disorders (ICDs).[11-13] The many
when scientists and academics began to express names given to this phenomenon recognize the vari-
their concern with the overuse of computers, which ous ways in which it has been regarded: compulsive
had just become widespread on college campuses computer use,[14] pathological internet use,[15] prob-
and in the business community. Weizenbaum,[3] a lematic internet use,[16] internet dependency,[17] in-
computer scientist, wrote extensively about the ternet addiction[18] and even internetomania.[19] The
‘compulsive programmers’ in his 1976 book Com- terms suggest a tension between those who view the
puter Power and Human Reason, while Zimbardo,[4] disorder as involving any abnormal or pathological
a research psychologist, wrote about computer ad- computer use and those who focus specifically on
diction as contributing to social isolation, opinions Internet usage. Because most investigators acknowl-
echoed by Boden[5] and Shallis.[6] It was not until the edge that this phenomenon involves a variety of
early 1990s that reports began to appear in the computer-use behaviours, we believe that any con-
medical and psychological literature for what Grif- sideration of the phenomenon needs to acknowledge
fiths[7] called a ‘technological addiction’, de- all forms of inappropriate and/or excessive comput-
scribed as a “non-chemical addiction involving er use, even when it does not involve Internet access.
human-machine interaction”. For example, Keep- Nonetheless, in this article, the term ‘Internet addic-
ers[8] described the case of a 12-year-old boy who tion’ will be used to describe the collective phenom-
turned to crime to fuel his preoccupation with video enon, but the terminology preferred by the respec-
games at a local arcade. In perhaps the first serious tive researchers is used when discussing their work.
analysis of the phenomenon, Shotton[9] described There are many definitions available for Internet
106 self-described ‘computer-dependent’ people, addiction. In the psychiatric literature, Black et al.[14]
and concluded that computer dependency occurs in described a series of ‘compulsive computer users’,
a small proportion of users. the only requirement of which was that subjects
Despite the attention Internet addiction has re- acknowledged “compulsive computer use that had
ceived, scientific understanding has lagged, in part contributed to personal distress, or social, occupa-
because of the lack of a common definition and tional, financial, or legal consequences”. Shapira et
consistent terminology. There are no generally ac- al.[20] further refined the definition of ‘problematic
cepted definitions for the condition, but investiga- internet use’ by enumerating operational criteria that
tors seem to agree that it involves problematic com- emphasize cognitive and behavioural aspects of the
puter usage that is time consuming and causes dis- disorder, as well as impairment characterized by
tress or impairs one’s functioning in important life subjective distress, and interference in social or oc-
domains. To some extent the impact of Internet cupational functioning; mania and hypomania
addiction remains ‘under the radar’ because its should be ruled out as causes of the disorder. These
many adverse consequences, including social isola- criteria were patterned after those developed by
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Internet Addiction 355
McElroy et al.[21] for compulsive shopping, consid- served that, while the terms ‘addiction’ and ‘com-
ered by many as a disorder of impulse control. pulsion’ that are frequently used to describe the
phenomenon are probably incorrect, the ‘intense
Young[13] has proposed criteria patterned after attachment to computers seems to be a real one’. In
the DSM-IV-TR criteria[22] for pathological gam- our view, Internet addiction is best considered a
bling. In employing her criteria, only non-essential disorder of impulse control because many of its
computer/Internet usage (e.g. non-business or non- features are similar to those of other disorders within
academic use) is considered. Internet addiction is the category, including pathological gambling, py-
present when five or more of the eight criteria are romania and kleptomania. These conditions are
present during the past 6 months, and mania has characterized by the failure to resist one’s impulses
been ruled out as a cause. She further breaks ‘In- to engage in a particular behaviour despite serious
ternet addiction’ into five subtypes and suggests that personal consequences, and are considered pleasura-
people typically become addicted to a particular ble and are seldom resisted. Until Internet addiction
application that acts as a trigger for excessive In- achieves recognition as a disorder, we recommend
ternet use. According to Young et al.,[23] Internet that clinicians use the Axis-I DSM-IV-TR category
addiction is a broad term covering a wide variety of ‘Impulse Control Disorder not otherwise specified’
behaviours and impulse control problems. The five and to indicate the specific problem within parenthe-
subtypes of Internet addiction are as follows: ses.[22]
1. Cybersexual addiction: This occurs in individuals It was recently suggested that the disorder be
who are typically engaged in viewing, downloading included in a new diagnostic category combining
and trading online pornography or are involved in behaviour and substance addictions.[25] In addition
adult fantasy role-play chat rooms. to Internet addiction, other ‘behavioural addictions’
2. Cyber-relational addiction: This occurs in people include pathological gambling, kleptomania, pyro-
who become overly involved in online relationships mania, compulsive shopping and compulsive sexual
or may engage in virtual adultery. Online relation- behaviour. In fact, the National Institute on Drug
ships become more important than real life ones, and Abuse considers behavioural addictions to be rela-
marital discord and family instability may result. tively pure models of addiction because they are not
3. Net compulsions: This subtype includes a broad contaminated by the presence of an exogenous sub-
category of behaviours, including online gambling, stance.[26] Whether Internet addiction is valid as a
shopping or stock trading. Significant financial distinct disorder or whether it is part of a larger
losses may result, as well as relational and job behavioural syndrome is unknown.
disruptions. Some authors have criticized attempts to catego-
4. Information overload: The World Wide Web has rize Internet addiction as a disorder. For example,
created a new kind of compulsive behaviour that both Griffiths[27] and Huisman et al.[28] have ques-
involves excessive web surfing and database search- tioned the existence of Internet addiction and have
es. These individuals spend a disproportionate criticized supportive research as methodologically
amount of time searching for, collecting and or- weak. Yet, ignoring Internet addiction only trivial-
ganizing information. izes and stigmatizes attempts to understand or treat
5. Computer addiction: Most computers come it.
equipped with pre-programmed games and people
become addicted to playing them at the cost of work 2. Assessment
performance or family obligations.
The diagnostic classification of Internet addic- As with any psychiatric or behavioural disorder,
tion remains elusive. There is currently no listing for the patient’s history forms the most important basis
the disorder in DSM-IV-TR[22] and Internet addic- for diagnosing Internet addiction. The initial goal of
tion remains an orphan disorder. Stein[24] has ob- the clinician is to define the extent of the problem
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356 Shaw & Black
through relatively non-intrusive inquiries, and then cupies their time and thoughts, and may contribute
to move on to more specific behaviours and use to a downward spiral of adversity. Normal computer
patterns. For general screening purposes, a clinician use can take on an addictive quality at times, such as
might ask the patient the following: when the person buys a new computer, first connects
to the Internet or upgrades their Internet service, or
•Do you feel overly preoccupied with using your is researching a topic of special interest. The clini-
computer or accessing the Internet? cian needs to exercise judgement before making a
•Do you ever feel that your computer (or Internet) diagnosis, and should be mindful of the need for
use is excessive, inappropriate or poorly control- evidence of distress or impairment before assigning
led? a diagnosis.
•Have your urges to use your computer (or the
Internet), or the usage itself, ever been overly 2.1 Rating Scales for Internet Addiction
time consuming, caused you to feel upset or
guilty, or led to serious problems in your life (e.g. Several screening instruments have been devel-
financial or legal problems, relationship loss)? oped to assess Internet addiction, although none
The psychiatric history of the patient should be have emerged as the ‘gold standard’. In one of the
carefully explored because many individuals with earliest studies, Egger and Rauterberg[29] devised a
Internet addiction will meet the criteria for co-mor- 46-item instrument to assess usage patterns, together
bid psychiatric disorders, such as major depression, with feelings and experiences regarding Internet
an anxiety disorder or another disorder of impulse use. They did not report on the measure’s psycho-
control (e.g. compulsive shopping). The presence of metric properties. Brenner[30] developed the Internet
co-morbid disorders may also suggest particular Addictive Behavior Inventory (IRABI), a 32-item
treatment strategies or approaches, as well as expla- questionnaire that probes a user’s Internet experi-
nations for the excessive Internet usage that may be ences, modelled after the section on substance abuse
helpful in counselling patients. in DSM-IV-TR.[22] The instrument was reported to
Clinicians should ask about past psychiatric treat- display good internal consistency (α = 0.87), but no
ment, including medications used, hospitalizations other information was provided.
and psychotherapy. Bipolar disorder should be ruled Young[31] created the Internet Addiction Test
out as the cause of the disorder because some indi- (IAT), a 20-item scale that rates degree of preoccu-
viduals with Internet addiction may excessively use pation, compulsive use, behavioural problems, emo-
the computer while manic. Although unlikely, the tional changes and impact of general functioning
patient’s history of physical illness, surgeries, drug related to computer use. This instrument was de-
allergies and medical treatment will help to rule out signed to (i) help respondents determine whether
medical causes as an explanation for the symptoms they meet Young’s criteria for Internet addiction;
(e.g. mass lesions), or identify conditions that may (ii) help self-identified Internet addicts determine
contraindicate the use of certain medications pre- which life domains the condition has impacted on;
scribed to treat the disorder. and (iii) for those concerned about another person’s
Internet usage, to rate that person or to give the test
Importantly, Internet addiction should be distin- to that person. The IAT appears to be valid and
guished from normal computer use, although in reliable.[32]
some cases it may be difficult to draw a clear dis-
tinction. In contemporary society, computer owner- Morahan-Martin and Schumacher[33] developed a
ship and usage, as well as Internet access, is wide- 13-item scale to assess problems associated with
spread. People in all walks of life spend many happy Internet use, including personal distress, academic,
and productive hours daily or weekly using their work or interpersonal issues, withdrawal symptoms
computer or accessing the Internet. Yet, for the or mood disturbance. These investigators consid-
Internet addict, computer usage significantly preoc- ered a respondent to be a pathological Internet user
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Internet Addiction 357
Table I. Surveys of Internet addiction prevalence
Survey Year Location Sample Prevalence (%) Gendera
Egger and Rauterberg[29] 1996 Switzerland Online, 450 people 10.6 Not addressed
Greenfield[36] 1999 US Online, 17 251 people aged 8–85 years 5.7 M = F
Morahan-Martin and 2000 US 277 undergraduate students 8.1 M > F
Schumacher[33]
Chou and Hsiao[39] 2000 Taiwan 910 university students 5.9 M > F
Whang et al.[37] 2003 Korea Online, 13 588 respondents 3.5 M = F
Kaltiala-Heino et al.[40] 2004 Finland 7229 youths 1.7 (boys) M > F
1.4 (girls)
Yoo et al.[34] 2004 Korea 535 chemistry students 0.9 M > F
Leung[35] 2004 China (Hong Kong) 699 people aged 16–24 years 38 F > M
Johansson and Gotestam[41] 2004 Norway 3237 youths aged 12–18 years 2 M > F
Niemz et al.[38] 2005 UK Online, 371 students 18 M > F
Kim et al.[42] 2006 Korea 1573 students 1.6 F > M
Aboujaoude et al.[2] 2006 US 2513 adults 0.3–0.7 Not addressed
Pallanti et al.[43] 2006 Italy 275 students 5.4 M = F
aInfluence of gender on prevalence: M > F indicates a higher prevalence among males; M = F indicates similar prevalence among
males and females; F > M indicates a higher prevalence among females.
F = female; M = male.
if he or she positively endorsed four or more items producing prevalence rates ranging from 0.3% to
on the scale. The authors also developed the Internet 0.7%. However, from 4% to 13% of respondents
Behavior and Attitudes Scale, a 25-item four-point endorsed one or more ‘markers’ consistent with
Likert-like scale, which explores the social aspects problematic Internet use, such as being ‘preoccupied
of Internet use and feelings of competency online. when offline’ or concealing one’s Internet use.
A full discussion of the many instruments devel- Thus, while all studies confirm that there are many
oped to diagnose or rate Internet addiction is beyond people who endorse problematic computer use, its
the scope of this article. true prevalence is unknown.
Internet addiction appears to have a male prepon-
3. Epidemiology derance based on data from the community and
There have been at least nine community and online surveys, as well as clinical samples. Of the 13
four online surveys to estimate the prevalence of surveys described in table I, six found a male pre-
Internet addiction (table I), with little uniformity of ponderance, two found a female preponderance and
the definitions employed or assessment methods three found an equal gender distribution; two stud-
used in these studies being shown. With one excep- ies, including Aboujaoude et al.,[2] did not report a
tion,[2] the studies focus on younger populations gender distribution. Of the clinical reports, Black et
rather than the wider adult population, perhaps re- al.[14] reported that of 21 people reporting compul-
flecting the view that this is primarily a disorder of sive computer use, 16 (76%) were men, and Shapira
younger persons. In studies that focus on younger et al.[11] reported that 11 of 20 subjects (55%) were
people, prevalence estimates range from 0.9%[34] men. Morahan-Martin and Schumacher[44] suggest-
to 38%.[35] The four online surveys[29,36-38] pro- ed that the gender distribution may be explained by
duced estimates ranging from 3.5%[37] to 18%.[38] the fact that men are more likely to express interest
Aboujaoude et al.[2] have reported perhaps the most in games, pornography and gambling, activities that
methodologically rigorous study, which involved have all been associated with problematic Internet
a random telephone survey of 2513 adults aged use.
18 years and older, and employed four criteria sets
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358 Shaw & Black
Both Black et al.[14] and Shapira et al.[11] report percent of subjects had at least one ICD, with com-
that the disorder has an age of onset in the late 20s or pulsive buying being the most frequent condition
early 30s. Furthermore, in both studies the subjects identified (19%). Other disorders included patho-
were in their 30s at the time of interview and report- logical gambling (10%), pyromania (10%), compul-
ed a 3-year history of problematic use. Black et sive sexual behaviour (10%), kleptomania (5%) and
al.[14] reported that their subjects were introduced to compulsive exercise (5%). There was no compari-
computers at a mean age of 17 years, and that there son group for this study.
was a lag-time of 11 years from initial computer use Shapira et al.[11] evaluated 20 subjects with prob-
to problematic computer use. Because computer use lematic Internet use, using the Structured Clinical
has become so widespread, and even young children Interview for DSM-IV,[48] to assess Axis-I disorders
are now well versed in computer usage and technol- and found that 70% met the criteria for a current
ogy, it is likely that the age at onset of problematic bipolar disorder (bipolar I disorder 55%; bipolar II
use has dropped. disorder 5%; schizoaffective disorder, bipolar type
While the natural history of Internet addiction is 10%). For lifetime disorders, these figures jumped
unknown, age-related differences have been docu- to 80% (bipolar I disorder 60%; bipolar II disorder
mented. Brenner[30] presented results from a survey 10%; schizoaffective disorder, bipolar type 10%).
of 563 Internet users who admitted to problematic These investigators also noted that 35% of their
use. While men and women did not differ in the subjects met the criteria for an ICD, including inter-
amount of time spent online or problems experi- mittent explosive disorder (10%), kleptomania
enced, older users reported fewer problems than (5%), pathological gambling (5%) and compulsive
younger users. buying (20%).
Quality of life was examined by Black et al.[14] While the reports of Black et al.[14] and Shapira et
using the Short Form-36 health survey.[45] In this al.[11] confirm the presence of co-morbid psychiatric
report, compulsive computer users had a specific disorders in Internet addicts, the rates for mood
deficit in general mental health, but their function- disorders reported by Shapira et al.[11] were much
ing was otherwise unimpaired. higher than those reported by Black et al.,[14] partic-
ularly for bipolar disorder. These high rates may
4. Psychiatric Co-Morbidity reflect ascertainment bias in that most subjects stud-
ied by Shapira et al.[11] had a history of receiving
Two clinical studies suggest that Internet addicts psychiatric treatment, while the subjects studied by
frequently meet the criteria for Axis-I and -II disor- Black et al.[14] were recruited through advertise-
ders; mood, anxiety, substance use and ICDs are ments and word-of-mouth, and had not received
particularly common. Black et al.[14] assessed 21 prior psychiatric treatment. It is important to recog-
subjects with compulsive computer use, using a nize the small sample sizes in these studies, and use
computer-interactive version of the Diagnostic In- caution in generalizing about co-morbidities until
terview Schedule (DIS).[46] Nearly 30% of the sub- further data become available.
jects met the criteria for a current disorder, with the Other researchers have employed a dimensional
most common being mood disorders (24%), anxiety approach to assess psychological status. In an early
disorders (19%), substance use disorders (14%) and study, Kraut et al.[49] reported that increased use of
psychotic disorders (10%). Nearly one-half of the the Internet was associated with higher ratings on
subjects met the criteria for a lifetime psychiatric measures of depression, loneliness and social isola-
disorder, including substance use disorders (38%), tion. These findings were compatible with those of
mood disorders (33%), anxiety disorders (19%) and Nie and Erbring[50] who reported that of the total
psychotic disorders (14%). The Minnesota Impul- number of people spending more than 5 hours online
sive Disorders Interview (MIDI)[47] was adminis- per week, 8% reported a decrease in social activities,
tered to assess the presence of the ICDs. Thirty-eight
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Internet Addiction 359
13% reported spending less time with family and dents were abstract thinkers who appear less con-
friends, and 26% reported having shorter phone forming to social convention and more emotionally
calls. These investigators concluded that the Internet reactive toward others.” It was hypothesized that
is an isolating technology, even more so than televi- these traits predispose to Internet addiction.
sion. 6. Family History
Young and Rodgers[51] administered the Beck
Depression Inventory to 259 ‘addicted users’ and Family history data are limited. In their study of
reported a mean score of 11.2, which suggests that 20 problematic Internet users, Shapira et al.[11] ob-
the group had elevated levels of depression. These served that all but one subject had positive family
investigators suggested that the low self-esteem, histories of psychiatric disorder. Thirteen subjects
poor motivation, fear of rejection and need for ap- (65%) had at least one first- or second-degree rela-
proval associated with depression contributes to in- tive with a depressive disorder, ten (50%) had a
creased Internet use, presumably as a way of coping relative with a bipolar disorder and 12 (60%) had a
with emotions. relative with a substance use disorder. However,
From a study of 445 individuals, 46% of whom these investigators did not ask if relatives had an
identified themselves as addicts, Petrie and Gunn[52] Internet addiction.
concluded that there was a significant relationship
between high Internet use and both depression and 7. Aetiology
introversion base on responses to both the Beck The cause of Internet addiction is unknown, al-
Depression Inventory[53] and Eysenck’s Introver- though speculation has centred on psychological,
sion/Extroversion Scale.[54] neurobiological and cultural influences. As with any
In a study of Korean school children, Yoo et psychiatric disorder, aetiology is often multifactori-
al.[34] found an association between scores on al and involves many mechanisms.
Young’s Internet Addiction Test and an attention-
deficit hyperactivity disorder rating scale. They pos- 7.1 Cognitive Behavioural Theory
tulated a relationship between the two disorders. According to Davis,[56] the cognitive behavioural
theory can explain the onset and maintenance of
5. Personality Disorders and Traits pathological Internet use. This model distinguishes
Black et al.[14] used the Personality Diagnostic between specific and generalized pathological In-
Questionnaire, revised[55] to assess Axis-II disorders ternet use. Specific pathological Internet use in-
among their subjects. Eleven subjects (52%) met the volves the misuse or abuse of specific functions on
criteria for at least one personality disorder, with the Internet, such as Internet gambling, shopping or
borderline personality disorder being the most fre- pornography. Davis[56] argues that these specific
quent (24%), followed by the narcissistic (19%) and behaviours would likely be displayed in another
antisocial (19%) types. Histrionic, avoidant, pas- venue if the Internet did not exist or was unavaila-
sive-aggressive and self-defeating personality disor- ble. Generalized pathological Internet use refers to a
ders were each identified in 14% of subjects, where- more global set of Internet behaviours that could not
as schizoid, schizotypal, obsessive-compulsive and exist outside the realm of the Internet, such as chat
dependent personality disorders were each present rooms, surfing the Web or email. The cognitive
in 10% of subjects. While there appears to be no behavioural model proposes that maladaptive cogni-
special ‘Internet addict personality’, Young and tions are critical to the development of generalized
Rodgers[51] found that persons dependent on the pathological Internet use behaviours. Examples
Internet ranked high in self-reliance, had a strong of maladaptive cognitions include self-doubt, self-
preference for solitary activities and tended to re- focused rumination, low self-efficacy and negative
strict their social outlets. They reported that “depen- self-appraisals. Dysfunctional behaviours that occur
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360 Shaw & Black
along with generalized pathological Internet use nin and dopamine neurotransmitters. SSRIs have
cognitions include compulsive Internet use that been used to treat Internet addiction, as described in
leads to negative outcomes at work, school or in section 9.1, in part because investigators have noted
personal relationships; denying or lying about In- similarities between Internet addiction and OCD,[10]
ternet use; and using the Internet to escape from a disorder known to respond to SSRIs.[58] Dopamine
one’s problems (e.g. depression, loneliness, etc.). has been theorized to play a role in ‘reward depend-
Over time, generalized pathological Internet use ence’, which has been claimed to foster ‘behavioural
cognitions and behaviours intensify and continue to addictions’ (e.g. pathological gambling, Internet ad-
produce negative outcomes, producing a diminished diction). There is currently no direct evidence to
sense of self-worth and increased social withdrawal. support the role of these neurotransmitter systems in
As symptoms of generalized pathological Internet the aetiology of Internet addiction.
use worsen, they exacerbate existing psychopatholo- Pallanti et al.[43] have observed that most work on
gies, resulting in a vicious dysfunctional cycle. Internet addiction has involved adolescent subjects
who, they observe, appear to be at increased risk for
7.2 Social Skills Deficit Theory this and other ‘addictions’. They hypothesize that
immaturity of the frontal cortical and subcortical
Caplan[57] has developed an explanatory theory monoaminergic system during normal neurodevel-
invoking deficient social skills. His first assumption opment underlies adolescent impulsivity, consid-
is that lonely and depressed individuals hold nega- ered the ‘foundation of disorders marked by distur-
tive views of their social competence. The second bance of reward motivation’.
assumption is that there are several features of com-
puter-mediated communications that are particularly 7.4 Cultural Mechanisms
attractive to persons who see themselves as low in
social competence; computer-mediated communica- Cultural mechanisms have been proposed to rec-
tion interactions give people a greater flexibility in ognize the fact that Internet addiction occurs wher-
self-presentation than face-to-face communication, ever computer usage is available. Reports on the
and one may omit or edit information they feel is disorder have come from the US,[44] Finland,[40]
negative or harmful. There is also a greater opportu- Hungary,[59] Italy,[43] Korea,[34,41] Norway,[42] South
nity to fabricate, exaggerate or intensify the positive Africa,[60] Taiwan,[39] the UK[38] and China.[35] It
aspects of one’s self. Thus, for some individuals the seems unlikely that Internet addiction can occur in
Internet represents a place where they can exercise a poorly developed countries where the availability of
control over the impressions others have of them. A computers and Internet access are limited, except
preference for online social interaction may stem perhaps among those in the academic, business or
from one’s belief that computer-mediated communi- government circles, or among the elite.
cation is easier (i.e. requiring less interpersonal so- 8. Clinical Symptoms
phistication), less risky (e.g. greater anonymity,
heightened sense of private self-awareness and low- In perhaps the earliest systematic study of 106
er sense of public self-awareness) and more exciting computer ‘dependents’, Shotton[61] found that, com-
than face-to-face communication. As Morahan- pared with two normative groups, computer depen-
Martin and Schumacher[44] put it, “The Internet can dents were less likely to be married and most were
be socially liberating – the Prozac of social commu- first-born children. They tended to buy computers as
nication”. soon as they were available, owned more computer
paraphernalia and computers than others and most
7.3 Neurobiological Theories admitted to becoming addicted from their first
Neurobiological theories tend to centre on dis- ‘hands-on’ experiences with computers. Additional-
turbed neurotransmission, particularly of the seroto- ly, they spent significantly more time using their
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Internet Addiction 361
computers at home and at work than did the others, amount of time spent online is less important than
and found it difficult to stop ‘computing’ when at the amount of distress or impairment the computer
the keyboard, often losing all sense of time. Shotton use leads to. Non-essential activities recorded in
writes: “Old hobbies disappeared and family activi- these studies included web surfing, chat rooms,
ties were no longer undertaken”.[61] Egger and email, games, designing web pages, pornography,
Rauterberg[29] also found that Internet addicts devel- newsgroups and shopping. These activities fre-
oped urges to use the Internet when offline, to feel quently intertwine; for example, people interested in
guilty or depressed when spending too much time pornography may spend hours searching websites
online and to report negative consequences for their for particular images or may spend many hours in
Internet use. chat rooms, as illustrated in a case reported by Stein
et al.[60] of a 42-year-old man preoccupied with
Black et al.[14] systematically assessed the experi- Internet pornography.
ences of 21 compulsive computer users. Subjects
admitted that their computer use led them to feel In her research of 596 subjects, 396 of whom
excited (52%), happy (48%) or powerful (19%), yet were considered computer dependent, Young[13] ob-
that it was sometimes used to assuage feelings of served that ‘dependents’ predominately used the
sadness (38%), frustration (10%) or irritability two-way communication functions on the Internet,
(14%). The subjects also reported positive aspects such as chat rooms, Multi-User Dungeons (MUDs, a
from their computer use; 52% reported that comput- computer programme or ‘cyberspace’, where users
er use distracted them from their problems or con- can take on the form of a character or avatar and
cerns, while 29% reported that they enjoyed ob- interact with each other), newsgroups or emails,
taining new information on the Internet. Most ad- while nondependents tended to use information-
mitted that their computer usage had caused seeking aspects of the Internet and email. Computer
problems with family or friends, or with work or dependents reported that their excessive Internet use
school. Nearly one-third had tried to cut back, but resulted in personal, family and occupational diffi-
observed that doing so made them more anxious. culties, with more than 50% rating these problems as
None felt that the disorder was sufficiently problem- ‘severe’. Young[13] also noted that marriages, dating
atic to seek treatment. Another aspect of the disor- relationships, parent-child relationships and close
der, as captured in the case reported by Belsare et friendships were disrupted by excessive use of the
al.,[62] is the sense of tension or arousal before suc- Internet as computer dependents spent less time in
cessfully logging on to the Internet, and the sense of face-to-face encounters and more time in front of
relief obtained once logged on. their computers. Marriages and dating relationships
were the most affected, as computer dependents
The most characteristic symptom of Internet ad- formed new relationships online, some of which led
diction is excessive ‘non-essential’ time spent on- to romantic interactions and ‘cybersex’ (i.e. online
line. This term refers to time not related to work or sexual fantasy role playing). Many computer depen-
academic pursuits, yet apart from this generality dents (52%) experienced severe financial problems
there is little agreement on what constitutes ‘non- as a result of excessive time spent online when
essential’ computer time and what is allowable in Internet providers billed for time spent online in-
contemporary society. Black et al.[14] reported that stead of the flat rate fee most charge today. In this
the 21 subjects in their study spent a mean of study, weekly Internet use of computer dependents
27 hours per week in non-essential computer use, ranged from 20 to 80 hours, with individual sessions
while Shapira et al.[11] reported a similar figure (28 lasting up to 15 hours. They reported sleep depriva-
hours per week) in their study of 20 subjects. In tion and lack of exercise, and were at an increased
contrast, the pathological Internet users described by risk for carpal tunnel syndrome, and back and eye
Morahan-Martin and Schumachers[44] spent a mean
of 8.5 hours online weekly. It may be that the actual strain. Lastly, 51% of computer dependents in the
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362 Shaw & Black
study reported significant work-related problems, noted that 14 of 24 trials (58%) employing a mood
mostly as a result of misusing their online access for stabilizer produced a favourable response. This fa-
personal use (i.e. ‘cyberslacking’). vourable response rate increased to 75% when trials
involving concurrently administered antidepressants
9. Clinical Management or stimulants were excluded from the analysis.
There are no evidence-based treatments for In- 9.2 Psychotherapy
ternet addiction, yet both psychotropic medication
and psychotherapy have been recommended. In ad- Cognitive behavioural therapy has been modified
dition, clinics exist in the US and elsewhere to treat to treat Internet addiction. Hall and Parsons[65] ob-
this disorder. With a single exception discussed in serve that these techniques are familiar to many
section 9.1, none of these approaches have been mental health treatment providers and can apply not
systematically studied; therefore, treatment recom- only to treating substance misuse but also
mendations are based on clinical experience, not ‘nonchemical addictions’, including Internet addic-
empirical data. Of course, the best strategy for some tion. They illustrate these techniques in the case of
people may be a self-imposed ban on computer an 18-year-old college student who was addicted to
access outside of work situations (where computer the Internet.
use can be monitored), which would entail getting Young[66] has recently developed a guide, which
rid of home PCs and cancelling their Internet ser- employs cognitive behavioural techniques, for ther-
vice. apists working with Internet addicts. She writes that
emotional states, maladaptive cognitions and life
9.1 Pharmacotherapy events can serve as triggers for Internet ‘binge-
behaviour’. Emotional triggers include negative
Hadley et al.[63] recently reported the results of a thoughts and emotions such as feelings of depres-
small open-label study of 19 subjects with a ‘com- sion, hopelessness and pessimism. Maladaptive cog-
pulsive-impulsive computer usage disorder’ who re- nitions, such as overgeneralization, selective ab-
ceived escitalopram for 10 weeks, followed by a straction, magnification or personalization,[67] may
9-week double-blind discontinuation phase. In the also be coupled with Internet misuse. Young[66] sug-
first phase, subjects experienced significant im- gests the following exercises to achieve abstinence
provement in hours spent in non-essential computer from problematic Internet: (i) practicing the oppo-
activity and other measures of response. Improve- site behaviour; (ii) using external stoppers, such as a
ment persisted throughout the second phase, al- timer signalling when an Internet session should
though there were no significant differences be- end; (iii) setting time limits; (iv) setting task priori-
tween the escitalopram and placebo groups. These ties to aid in Internet goals during each Internet
results suggest that the improvement experienced by session; (v) using reminder cards (posted on the
the subjects could have been a result of the ‘placebo computer) with a list of the five major problems
effect’. Sattar and Ramaswamy[64] had earlier re- caused by the Internet addiction, and a parallel list of
ported, in a single case, that escitalopram reduced the five major benefits of cutting down on Internet
the subject’s urges for online gaming. use; and (vi) taking a personal inventory, whereby
Shapira et al.[11] reported retrospective data on the therapist helps the client cultivate alternative
the medication management of 15 individuals with activities that take him/her away from the computer.
problematic Internet use. Five of 14 (36%) antide-
pressant monotherapy trials resulted in a favourable Self-help books and tapes are available online
response, defined as a ‘moderate’ or ‘marked’ re- and may be helpful to some people with Internet
duction in Internet use, with only two of nine (22%) addiction.[31] Support groups are available in some
SSRI trials (e.g. fluoxetine, paroxetine, sertraline) areas, as well as online. These groups may provide a
resulting in favourable responses. Shapira et al.[11] sense of mutual support and encouragement that
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Internet Addiction 363
some people might find helpful. Some people with ologies or pathophysiologies is unexplored, as is
Internet addiction develop financial problems and family history. It is not known whether certain psy-
may benefit from financial counselling. Marriage chiatric disorders, such as alcohol and other drug use
(or couples) counselling may be helpful when the disorders or depression, run in these families. These
Internet addiction in one member of the dyad has associations may help investigators to better under-
disrupted the relationship. Likewise, family therapy stand the issue of classification of Internet addiction.
may be helpful when the behaviours of an Internet Some investigators suggest a relationship to OCD,
addict have disrupted the family unit. Interestingly, others to the addictive disorders and some to the
a half-way house for adolescents with Internet ad- ICDs. It could be that all investigators are correct in
diction has opened in China. The length of stay is that subgroups of Internet addicts could be motivat-
from 10 to 14 days and treatment includes group ed by different underlying diatheses that correspond
therapy, medication, acupuncture and sports.[68] to these different diagnoses. Finally, while the disor-
der has become widespread, there have been no
systematic studies of proposed treatments, and it is
10. Conclusion not clear which patients might be helped with cogni-
Interest in Internet addiction has grown in the tive behavioural therapy or whether medication is of
past decade, leading to a better understanding of the value in treating the disorder.
condition, yet there is little agreement regarding its
Acknowledgements
definition. The lack of agreement has complicated
attempts to study its prevalence and gender distribu- Dr Black has received research support from Shire and
tion. Of interest is whether the prevalence is contin- Forest Laboratories; speaker’s bureau honoraria from Pfizer;
uing to grow as the use of computers and Internet and honoraria for other consulting from Forest Laboratories
and Shire. Ms Shaw reports no conflicts of interest that are
access expand. Perhaps the prevalence will not sta- directly relevant to this manuscript. No sources of funding
bilize until computer access reaches a saturation were used to assist in the preparation of this review.
point wherein all but the most isolated communities
have access. Nonetheless, research suggests that the References
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